Patient Request for Treatment,
Representations and Consent

I acknowledge and understand that there is an increased risk that COVID-19 can be transmitted in any place of public accommodation, including a dental office. Even after following protocols set by the American Dental Association and our state dental association, it is still possible to contract COVID-19 while at a dental office.  This office is following all guidelines to minimize the risk of transmission while you are seeking care. 

However, it is important to understand that social distancing of 6 feet is not possible while the dental practitioner and authorized staff are in the physical act of providing dental care that you need.  In addition, the COVID-19 virus has an incubation period during which carriers of this virus may not show signs or symptoms and may still be contagious.

I consent to the performance of the treatment proposed by my dentist.